Healthcare providers, such as pharmacies, typically generate healthcare claim transactions on behalf of patients or customers. Once generated, the healthcare claim transactions are typically output for communication to payers and claims processors for adjudication purposes. Healthcare transactions are then typically completed following the adjudication of the relevant claim transactions. For example, drugs and/or other products are typically dispensed to patients or customers.
Following the completion of a healthcare transaction, there is a possibility that the healthcare claim transaction and/or the underlying healthcare transaction will be audited. For example, a claims adjudicator or payer may conduct or direct the completion of an audit relating to a healthcare transaction. Any discrepancy found with the healthcare transaction during an audit often leads to a charge-back, thereby resulting in a financial loss for the healthcare provider. Audit activity has steadily increased in recent years. One of the top economic audit issues impacting healthcare providers relates to “directions for use” information associated with prescriptions. In the event that a physician fails to provide appropriate and/or specific directions for use that satisfy payer or adjudicator guidelines, a charge-back is typically generated.
The problem with insufficient directions for use information is compounded because directions for use information is not included in healthcare claim transactions. The current National Council for Prescription Drug Programs (“NCPDP”) telecommunications standard does not support the inclusion of directions for use information. Accordingly, healthcare claim transactions cannot currently be evaluated in order to determine whether appropriate directions for use have been provided for a product by a prescribing physician. Therefore, an opportunity exists for improved systems and methods for identifying healthcare transactions with a risk of failing to include appropriate directions for use.